Nearly all spine surgeons today undergo fellowship training, with many fellowships at hospitals and academic medical centers. However, Texas Back Institute in Plano launched a fellowship program more than 25 years ago that gives fellows a unique opportunity and perspective.
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"We decided to start a fellowship program because most of us came from fellowships that were preceptorships," says Richard Guyer, MD, Co-Founder of Texas Back Institute, Director of the Spine Fellowship Program and Chairman of the Board for the Texas Back Institute Research Foundation. "We were trained by some of the finest spine surgeons in the field. We also wanted train future fellows and allow them to carry out research which gave us the opportunity to grow along with them.”
The fellowship began in 1987 with one fellow per year and grew to five5 per year. The program has become an accredited graduate medical education program. The accreditation process helped Dr. Guyer and his colleagues identify strengths and weaknesses within the program, which drove continued growth and excellence throughout the years.
Initially focusing on degenerative disease, the practice and fellowship now covers all areas of spine including MIS, trauma, tumor and adult and pediatric deformity as well. Here are Dr. Guyer's thoughts on the fellowship program and where training is headed in the future.
Q: What makes the fellowship program at Texas Back Institute unique?
Dr. Richard Guyer: We give our fellows exposure to all areas of spine. Traditionally, fellows would just have exposure to one surgeon and learn his techniques. Now they have exposure to 15 different surgeons with different expertise and techniques. That gives the fellows an excellent, well-rounded experience. From our fellowship, they can choose to go into private practice or academics.
Our full academic program includes the fellows giving lectures at Friday mornings Grand Rounds. They are also exposed to invited prominent spine surgeons who also give grand rounds. We have a monthly journal club where we allow fellows — with our guidance — to cover topics they are interested in. We have interesting case conference following Grand Rounds and teach a biweekly comprehensive spine curriculum. When they leave us, they have a firm foundation upon which they can build onto in the future.
Q: What opportunities do spine fellows have to grow and develop during their training?
RG: During their stay at TBI, they are exposed to a large surgical volume which includes exposure to the latest techniques and are required to carry out two2 research projects. They have the opportunity to present their work at various spine meetings. Because of our faculty expertise, they are also given the opportunity also to publish and write papers and book chapters. They meet many visiting lecturers from the US and abroad.. At the North American Spine Society Annual Meeting we hold a fellow's reunion for former and current fellows. It is a wonderful networking opportunity for them and it is very gratifying to see many of our past TBI fellows.
When our fellows graduate, they can connect with the greater than 110 fellows and international fellows who have graduated from our program. Many fellows end up finding jobs with old fellows. We have now trained surgeons in 33 states and 11 countries.
Q: What is the most rewarding aspect of training so many future spine surgeons?
RG: The most rewarding thing for me to see the transformation of the fellows from an orthopedic surgeon or neurosurgeon into a spine surgeon. They all come with varying experience but as time goes on I see the light bulb go on knowing that they finally “got it” as I watch their skills develop and they become confident in evaluating various spine problems.
My partners and I enjoy knowing we have made an impact on the fellow's career and development into a competent spine surgeon of whom we are proud.
Q: What are the biggest challenges for developing an advanced and sought-after fellowship program?
RG: There are several challenges. As time goes on, techniques and technology change. When we began the fellowship, spine was a field that was just beginning to flourish; for exmple we have many minimally invasive techniques and robotic-guided surgery. We have to make certain the surgeons who are in the group training our fellows keep up with these skills and teach current techniques and stay on the cutting edge.
Our practice is continually evaluating and incorporating new technology in. That's part of being involved in research and helping move the science of spine forward and being leaders. The fellows challenge us to keep up the latest literature by their questions and queries. There is a constant back-and-forth discourse between the training surgeons and fellows. It keeps all of us young and abreast of the latest technology.
Q: What lessons are most important for training fellows to learn?
RG: The most important thing we teach our fellows is how to think critically in their evaluation of patients and help them perfect their decision-making. Most come in with good technical skills which we can hone during the year. We want to teach our fellows to be good thinkers and make good decisions based on current best practices and knowledge we have today.
We try to expose them to a balanced time in the clinic and operating room. They should glean the experience and wisdom from treating many patients. After the fellows evaluate the patients in the office we discuss their findings and palnplan. We want them to become expert physicians who are compassionate; not just surgeons who operate based on X-rays.
Q: Where do you see spine surgeon fellowships and training programs headed in the future?
RG: Spine is becoming so complex that a fellowship might not be just one year in the future. We give a broad fellowship, but one could spend an entire year focused on just minimally invasive or deformity training. We may see a change in the whole educational process, shortening the residency programs to add another year to fellowships, because we are seeing more residents who know they want to focus on spine during their second or third years.
I think it would make more sense to extend the fellowship time, but it would take a while for residency programs to come to that conclusion. Spine surgery is becoming more complex and techniques are changing quickly, so I think this is a field that will continue to flourish.
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